Glucocorticoids are the first-line treatment for various immune-inflammatory and allergic diseases. For example, the autoimmune diseases include more than 70 chronic disorders that affect about 5% of the US population, and include those that most occur in women (>80%) such as Sjogren's syndrome, SLE, autoimmune thyroid disease (Hashimoto's thyroiditis and well as Graves' disease) and scleroderma, or relatively common among women (60-75%) such as rheumatoid arthritis (RA), multiple sclerosis (MS) and myasthenia gravis; or those that occur at a similar female:male ratio such as sarcoid and inflammatory bowel diseases. Glucocorticoid insensitivity presents a profound management problem in those diseases/conditions treated with steroids, and twenty to forty percent of patients may fail to achieve disease control. The glucocorticoid insensitivity may present as relatively or totally refractory to glucocorticoid therapy; unresponsive or intolerant to corticosteroids; unresponsive to an adequate induction dose of corticosteroids; initially responsive to corticosteroids but relapses quickly upon drug withdrawal or dose tapering (corticosteroid dependent); corticoid resistant, e.g., requires a very high dose treatment; or “difficult to treat” or severe condition. For example, 20-30% of patients with severe and steroid-resistant Crohn's Disease will not respond to steroid therapy (Michetti P, Mottet C, Juillerat P, Felley C, Vader J-P, Burnand B, Gonvers J-J, Froehlich F: Severe and Steroid-Resistant Crohn's Disease. Digestion 2005; 71:19-25).
Diseases/conditions related to glucocorticoid insensitivity may include: refractory inflammatory bowel disease, such as Refractory ulcerative colitis and children with severe Crohn disease, corticosteroid refractory asthma or glucocorticoid resistant asthma or symptomatic corticosteroid dependent asthma, desquamative interstitial pneumonia refractory to corticosteroid, refractory inflammatory myopathies, refractory myasthenia gravis, refractory pemphigus vulgaris, methotrexaterefractory RA patients, refractory nephrotic syndrome in adults, corticosteroid dependent systemic lupus erythematosus (SLE), primary Sjogren's syndrome, systemic vasculitis and polymyositis, chronic graft-versus-host disease, corticosteroid dependent or refractory multiple sclerosis, refractory sprue-like disease, steroid-resistant sarcoidosis, refractory mucosal lesions of pemphigus vulgaris, refractory Schnitzler syndrome, resistant dermatitis of the head and neck, severe refractory atopic dermatitis, refractory Idiopathic thrombocytopenia purpura, refractory orbital myositis, refractory or recurrent lymphomas, critically ill patients with sepsis or acute respiratory distress syndrome (ARDS) or relative adrenal insufficiency, corticosteroid-dependent conditions (e.g., rosacea, polymyalgia rheumatic, giant cell arteritis, polymyositis, dermatomyositis, Kawasaki syndrome, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, Stiff man syndrome etc.,). Glucocorticoid insensitivity has serious health, societal, and economic costs. For example, a small percentage of patients with asthma (5-10%) have severe corticosteroid-refractory condition that often fails to respond but these patients account for >50% of the total asthma health care costs.
Glucocorticoids suppress inflammation mainly as a result of both activation of anti-inflammatory genes and suppression of pro-inflammatory genes. The activation of anti-inflammatory gene expression starts as glucocorticoid binds cytosolic glucocorticoid receptor (GR), which is activated and translocates to the nucleus. Once in the nucleus, it binds to glucocorticoid response elements (GREs) and transcriptional coactivator molecules, and causes acetylation of core histones, which leads to the expression of anti-inflammatory genes. Inflammatory stimuli switch on multiple inflammatory genes that encode cytokines, chemokines, adhesion molecules, inflammatory enzymes, and receptors via pro-inflammatory transcription factors, such as nuclear factor κB (NFκB) and activator protein 1, and the recruitment of co-repressor molecules. Activated glucocorticoid receptors bind to the coactivators in the nucleus to inhibit histone acetyltransferase (HAT) activity directly and recruit histone deacetylase 2 (HDAC2), leading to suppression of the activated inflammatory genes.
Several possible molecular mechanisms of glucocorticoid resistance have been recognized, and include genetic susceptibility, lack of or defective binding to GR and translocation, reduced GR expression, lack of co-repressor activity, or enhanced activation of inflammatory pathways. For example, glucocorticoid receptors might be phosphorylated by several kinases (e.g., p38 mitogen-activated protein kinase, c-Jun N-terminal kinase, and extracellular signal-regulated kinase) that results in the defective binding, alterations in their stability, translocation to the nucleus, binding to DNA, and interaction with other proteins. Excessive activation of the transcription factor activator protein 1 can prevent GRs binding to glucocorticoid response elements (GREs) or inhibiting nuclear factor κB; Nitric oxide (NO) can nitrate tyrosine residues on GRs; GRs can also be ubiquitinated (Ub), which results in degradation of GR by the proteasome; reduced histone deacetylase-2 (HDAC2) expression, raised macrophage migration inhibitory factor, and increased P-glycoprotein-mediated drug efflux (Peter J Barnes, Ian M Adcock. Glucocorticoid resistance in inflammatory diseases. Lancet 2009; 373: 1905-17).
The clinical and biological mechanisms of steroid-dependency are not well understood compared with those determining steroid-resistance. Steroid-dependency and steroid-resistance may share some common intrinsic mechanisms while other mechanisms are simply clinical or pharmacological.
Many attempts have been made to ameliorate the effects of glucocorticoid insensitivity. A common approach is to use broad-spectrum anti-inflammatory treatments such as immunosuppressive or immunomodulators agents (e.g., cyclosporine, methotrexate, gold, 6-mercaptopurine, biologic products such as intravenous immunoglobulin and Mepolizumab), and calcineurin inhibitors (e.g., cyclosporin, tacrolimus). Various approaches have been proposed or developed to reverse glucocorticoid resistance such as p38 MAP kinase inhibitors, JNK inhibitors (decrease API), Vitamin D in steroid-resistant asthma (increase regulatory T cells), MIF inhibitors, Histone deacetylate-2 activators, Theophylline, Phosphoinositide-3-kinase-δ inhibitors, antioxidants, iNOS inhibitors and P-glycoprotein inhibitors. The use of progestogen for reversing the glucocorticoid-insensitivity has not been discussed or presented anywhere, and the present invention represents a significant, surprising and unexpected advance in the art.
The different approaches for management of glucocorticoid insensitivity have had limited success. Some agents may work in a condition, but not others. Methotrexate is effective for rheumatoid arthritis, but it might be ineffective in cases of glucocorticoid-resistant inflammatory bowel disease caused by increased P-glycoprotein expression. Similarly, calcineurin inhibitors are useful in some patients with glucocorticoid-resistant inflammatory bowel disease, but they have not proven to be effective in glucocorticoid-resistant asthma. Further, the uses of those agents are often associated with significant adverse events. A high percentage of patients (60-70%) may fail treatment with methotrexate because of side effects. Phosphodiesterase-4 inhibitors for COPD and inflammatory conditions have dose-limiting side-effects of nausea, diarrhea, and headaches. Significant toxicity and side-effects have hampered the drug development programs for p38 MAP-kinase inhibitors and selective inhibitors to block inhibition of NFκB kinase (IKKβ)/NFκB (Peter J Barnes, Ian M Adcock. Glucocorticoid resistance in inflammatory diseases. Lancet 2009; 373: 1905-17).
Given that a considerable proportion of patients with autoimmune, allergic, and lymphoproliferative diseases are refractory to glucocorticoid therapy as well many different inflammatory diseases share similar molecular mechanisms in glucocorticoid insensitivity, there exists a heretofore unmet need in the art for methods for developing a common therapeutic strategy to reverse the steroid-insensitivity. The use of progestogen, in accordance with the present invention, has been discovered to present a surprising, unexpected, and also practicable method to help patients with diseases/conditions that are unresponsive or intolerant to corticosteroids or corticosteroid dependent and resistant.
Progestogen products have been extensively used in a wide range of reproductive diseases/conditions for more than 60 years, and known to have anti-inflammatory effects. The majority of studies related to inflammatory responses were conducted in pregnancy-associated models. Progesterone/PR Maintains Uterine Quiescence via Antiinflammatory Actions (Carole R. Mendelson. Minireview: Fetal-Maternal Hormonal Signaling in Pregnancy and Labor Molecular Endocrinology 23: 947-954, 2009). Gellersen (2009) provided a comprehensive review of non-genomic progesterone actions, and summarized possible mechanisms of progesterone anti-inflammatory effects, including that progesterone opposes prostaglandin production in the uterus of pregnancy, partially by inhibiting cyclooxygenase (COX-2) expression; immunoregulatory function in human T-lymphocytes via G-protein activation and K+ channel Inhibition; progesterone-induced blocking factor (PIBF) acts on the phospholipase A2 enzyme, interferes with arachidonic acid metabolism, induces a Th2 biased immune response, and exerts an anti-abortive effect by controlling NK activity (Gellersen B et al. Non-genomic progesterone actions in female reproduction Human Reproduction Update, Vol. 15, No. 1 pp. 119-138, 2009). Another review by Challies (2009) suggests other possible mechanisms: progesterone blocks mitogen-stimulated lymphocyte proliferation, modulates antibody production, decreases the oxidative burst of monocytes, reduces the production of proinflammatory cytokines by macrophages in response to bacterial products, and alters cytokine secretion of T-cell clones to favor IL-10 production, upregulates Toll-like receptor 4 (TLR-4) expression and suppresses TLR-2 response to infection in intrauterine tissues, resulting in a protective role with respect to preterm delivery, inhibits basal and cytokine-enhanced matrix metalloproteinases (MMP)-1 and MMP-3 expression in cultured decidual cells demonstrating protection against preterm delivery (Challis J R et al. Inflammation and Pregnancy Reproductive Sciences 2009; 16; 206). Since the concept of using progestogen for reversing the glucocorticoid-insensitivity has not been disclosed, taught, suggested, discussed, or presented anywhere, the present discovery represents a significant and unexpected advance in the art.
Menstrual cycle-related exacerbation of common medical conditions is a well-recognized phenomenon, and may include migraine, epilepsy, asthma, irritable bowel syndrome, autoimmune progesterone dermatitis and stomatitis, and diabetes. Exacerbation is influenced by hormonal changes of the menstrual cycle. The majority of these effects occur during the luteal and menstrual phases of the cycle. For example, premenstrual asthma denotes worsening of asthma symptoms shortly before and/or during menstruation. Accurate documentation of symptoms on a menstrual calendar allows identification of women with cyclic alterations in disease activity. Female sex-steroid hormones play an important role but the exact mechanism is still unknown. Several theories exist to explain these menstrual cycle-related effects. These include fluctuations in levels of sex steroids, cyclic alterations in the immune system, increased airway hyperresponsiveness, changing perceptions of disease severity brought about by premenstrual alterations in mood, as seen in premenstrual syndrome, and allergy to self-hormones particularly progesterone. Menstrual cycle-related exacerbation might be ameliorated by progesterone supplementation [Allison M. Case and Robert L. Reid. Menstrual cycle effects on common medical conditions. Journal Comprehensive Therapy Issue Volume 27, Number 1/March, 2001; Beynon H L. Severe premenstrual exacerbations of asthma: effect of intramuscular progesterone. Lancet—13-Aug.-1988; 2(8607): 370-2; Roby, Russell R et al. Sublingual progesterone dilutions as bronchodilator in asthmatic females. World Allergy Organization Journal: November 2007—Volume—Issue—p S148].
Glucocorticoid insensitivity often correlates with other factors believed to contribute to relatively or totally refractory responses to glucocorticoid therapy. These include the various risk factors noted above such as genetic susceptibility, abnormalities in the glucocorticoid receptor gene, viral infection and oxidative stress. For example, oxidative DNA damage is known to be a primary cause of the process of mutation and a leading cause of aging, cancer and other diseases because guanine, one of the four basic nucleotides that make up DNA and form the genetic code of life, is particularly sensitive to oxidative damage, and a predominant number of genetic mutations are linked to guanine. Thus, there exists a need in the art for methods for reducing the occurrence of glucocorticoid insensitivity related conditions (e.g., refractory asthma, refractory rheumatoid arthritis, refractory inflammatory bowel disease, chronic obstructive pulmonary disease and acute respiratory distress syndrome) associated with such risk factors.
A menstrual rhythm has been documented for exacerbations of asthma, which may have important clinical relevance to the patient with severe asthma. Beynon et al. (1988) reported 3 cases of severe premenstrual exacerbations of asthma that were treated with intramuscular progesterone. The patients hadn't responded to conventional treatment, including high-dose corticosteroids. In all cases there was a fall premenstrually in peak flow rate. The addition of intramuscular progesterone (100 mg daily in two cases and 600 mg twice a week in one) to the regimen eliminated the premenstrual dips in peak flow, and daily doses of prednisolone were reduced in the three patients. The above-described study and results are described in Beynon et al. (Severe premenstrual exacerbations of asthma: effect of intramuscular progesterone. Lancet—13-Aug.-1988; 2(8607): 370-2.).
In another study, Russell R et al (2007) tested the hypothesis that pre-menstrual asthma is associated with allergy to self-hormones particularly progesterone by using sublingual progesterone dilutions as bronchodilator. Sixteen females who had a previous diagnosis of severe asthma and who were nebulization dependent were selected for the study. Spirometric studies were performed on these subjects. Study showed changes over time of the forced expiratory volume in one second (FEV1), the forced vital capacity (FVC), and the peak expiratory flow (PEF) measured at three times: (1) before treatment, (2) after sublingual normal saline treatment (3) after sublingual progesterone treatment. After treatment with sublingual progesterone, twelve of the sixteen patients (75%) experienced a bronchodilator effect (greater than 12% increase) in either FEV1 or FVC. Eight (50%) experienced an increase in both FEV1 and FVC. Eight (50%) had an increase of 27% or greater in PEF. The above-described study and results are described in Russell R et al. (Sublingual progesterone dilutions as bronchodilator in asthmatic females. World Allergy Organization Journal: November 2007—Volume—Issue—p S148.).
Activation of mitogen-activated protein kinases (MAPKs) is a critical event in mitogenic signal transduction. Ruzycky A L (1996) determined the effects of 17 beta-estradiol and progesterone on mitogen-activated protein kinase expression and activity. MAPK expression and activity was examined in uterine smooth muscle from rats pretreated with estradiol-17 beta alone or with estradiol-17 beta and progesterone. MAPK expression was detected by immunoblotting using erk1/2 antibodies. MAPK activity was detected by measurement of the phosphorylation of a MAPK-specific peptide sequence of myelin basic protein. Steroid treatment caused a modest (20%) decline in erk 1 and 2 expression in membrane and cytosolic fractions. Both estrogen and progesterone increased MAPK tyrosine phosphorylation and membrane-associated MAPK activity. Steroid treatment increased cytosolic MAPK tyrosine phosphorylation, but not enzymatic activity. The above-described study and results are described in Ruzycky A L (Effects of 17 beta-estradiol and progesterone on mitogen-activated protein kinase expression and activity in rat uterine smooth muscle. Eur J Pharmacol. 1996 Apr. 11; 300(3):247-54).